Foundations Chapter 19 PrepU

a nursing student is attending a clinical rotation in a labor/delivery/postpartum unit and is able to see a vaginal devilry for the first time. the student takes a picture of the newborn and posts it on a social media site. what action may occur related to this privacy violation?

-the student will be dismissed from the nursing program as well as fined for a HIPAA violation

a nurse has administered 1 unit of glucose to the client as per order. what is the correct documentation of this information? a. 1 bottle of glucose b. 1U of glucose c. 1 unit of glucose d. one U of glucose

1 Unit of glucose

a health care facility plans to evaluate and revise the plan of care for a client based on the clients health care records. the physician, dietitian, and nurse involved in the clients care are required to collate all of the information for easy access. Which style would the nurse conclude that the facility is following in order to record the client details? a. narrative charting b. SOAP charting c. PIE charting d. FOCUS charting

SOAP charting

when recording data regarding the clients health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. which of the following styles of documentation is the nurse implementing? a. FOCUS charting b. SOAP charting c. narrative charting d. PIE charting

SOAP charting

which clinical situation is addressed by the provisions of the HIPAA? a. a client has asked a nurse if he can read the documentation that his physician wrote in his cart b. a client who resides in indiana has required hospitalization during vacation in hawaii c. a client wishes to appeal her insurance companys refusal to reimburse for a diagnostic test d. a client has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer

a client has asked a nurse if he can read the documentation that his physician wrote in his chart

a community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease, and their families. providing this information is an example of: a. a referral b. conferring c. a consultation d. reporting

a referral

besides using the health care records, which form of communication should the nurse use to provide client details to the health care team coming on duty in the next shift? a. team conferences b. telephone calls c. change-of-shift reports d. client assignments

change of shift reports

a nurse is part of a team that will be working in a new orthopedic unit to determine the most appropriate method for documentation. the team agrees to initiate the practice of an abbreviated form of the documentation that requires less nursing time and readily detects changes in client status. which documentation method would the group most likely suggest? a. FOCUS data, action, and response note b. narrative notes c. charting by exception d. problem, intervention, and evaluation note

charting by exception

a hospital is changing the format for documentation in an attempt to decrease the amount of time the nurses are spending on charting. the new type of charting will require that the nurses document the significant findings as a narrative note, in a shorthand method using well-defined standards of practice. which of the following best defines this type of charting? a. variance charting b. charting by exception (CBE) c. FOCUS charting d. problem, intervention, evaluation (PIE) charting

charting by exception (CBE)

a nursing student is preparing a presentation on client records and documentation. what information should the student include in the presentation? a. communication is the primary purpose of clients records b. clients should keep the original record at home in a fire proof safe c. physicians will not review nurses documentation in the clients record d. nurses should not document progress notes in a clients record

communication is the primary purpose of clients records

the nurse mistakenly documented one clients assessment data on another clients health care record. what action should the nurse take? a. use a dark colored felt tip pen to black out the error b. draw a single line through the error, initial it, and write the correct entry c. use correction fluid to cover the error and writhe the correct entry over it d. replace the record sheet and write the correct entry on the new sheet

draw a single line through the error, initial it, and write the correct entry

when maintaining health care records for a client, the nurse knows that a health care record also serves as a legal document of evidence. what should the nurse do to ensure legal defensible charting? a. ensure that the clients name appear on all pages b. use abbreviations wherever possible c. record all facts and subjective and subjective interpretations d. leave spaces between entries and signature

ensure that the clients name appears on all pages

a client will be transferred from the surgical unit to the rehabilitation unit for further care. which information would the nurse expect to include when preparing the verbal handoff report? a. clients intake for previous meal b. clients family members c. clients admission number d. current client assessment

current client assessment

is it acceptable for the nurse to accept a verbal order from the physician in which situation? a. prior to the client leaving the floor for therapy b. upon admission of the client to the unit c. immediately prior to discharge d. during a medical emergency

during a medical emergency

a nurse on a night shift entered an older adults clients room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. after assessing the client and assisting into the bed, the nurse has completed an incident report. what is the primary purpose of this particular type of documentation? a. following up the incident with other members of the care team b. gauging the nurses professional performance over time c. protecting the nurse and the hospital from litigation d. identifying risks and ensuring future safety for clients

identifying risk and ensuring future safety for clients

the health care provider approaches the nurse caring for the client in room 25 and states, "the client is a friend of mine. what treatment is being given?" what response by the nurse is most appropriate? a. inform the health care provider of a busy schedule preventing answering any questions at this time b. open the health care record for the doctor to review the treatment ordered c. inform the health care provider that client permission is needed to release any information d. tell the health care provider to contact the provider caring for the client to obtain any information

inform the health care provider that client permission is needed to release any information

which flow sheet provides the health care provider with information on an ongoing record of fluid loss? a. health assessment flow sheet b. intake and output graphic sheet c. critical care flow sheet d. vital signs graphic sheet

intake and output graphic sheet

a health care provider suggests that the nurse use the computer terminal that is available at the point of care or at the clients bedside. what is the probably reason for this suggestion? a. it solves the space constraint in the hospital b. it keeps the nurse close to the source of the data c. there are limited computer modules available d. the client needs to check the entry as well

it keeps the nurse close to the source of the data

when documenting the care of a client, the nurse is aware of the ned to use abbreviations conscientiously and safely. this includes: a. ensuring that abbreviations are understandable to clients who may seek access to their health records b. using only abbreviations whose meaning is self-evident to an educated health professional c. using only those abbreviations that are defined in full at another location in the clients chart d. limiting abbreviations to those approved for use by the institution

limiting abbreviations to those approved for use by the institution

a nurse is documenting the effectiveness of a clients pain management on the clients record. which documentation is written correctly? a. mr gray appears to have a low tolerance for pain and frequently reports intense pain b. my gray reports that on a scale of 0 to 10, the pain he is experiencing is a 3 c. mr. gray is receiving sufficient relief from pain medication d. mr. gray appears comfortable and is resting adequately

mr. gray reports that on a scale of 0 to 10, the pain he is experiencing is a 3

when taking a telephone order from a physician, the nurse verifies that they understand the order by: a. faxing the written order to the physicians office b. confirming the order with the nurse manager c. asking the physician to summarize the orders given d. repeating the order back to the physician

repeating the order back to the physician

when documenting information in a clients health care record, what should the nurse do consistently for each entry? a. obtain a signature from the physician b. sign each entry by name and title c. report each observation to the physician d. provide the day of the week on the entry

sign each entry by name and title

which example may illustrate a breach of confidentiality and security of client information? a. the nurse informs a colleague that she should not be discussing client information in the hospital cafeteria b. the nurse accesses client information on the computer at the nurses station, then logs off before answering a clients call bell c. the nurse provides information over the phone to the clients family member who lives in a neighboring state d. the nurse provides information to a professional caregiver involved in the care of the client

the nurse provides information over the phone to the clients family member who lives in a neighboring state

a nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the clients friend asks the nurse for the clients record, but the nurse refuses. the nurses refusal is based on the understanding that which people would be entitles to access of the clients records? a. any family member of the client b. close friends of the client c. those directly involved in the clients care d. health care professionals of the facility

those directly involved in the clients care

a new graduate is working at a first job. which statement is most important for the new to follow? a. only document changes in the clients status b. use abbreviations approved by the facility c. use PIE charting even if it is not the institution charting method d. document lengthy entries using complete sentences

use abbreviations approved by the facility

the nurse should utilize ISBARR communication (introduction, situation, background, assessment, recommendation, read back) during which clinical situation? a. when transferring a client from the emergency department to the acute care unit b. when documenting the care that was provided to a client whose condition recently deteriorate c. when reporting to a clients family member or significant other d. when preparing to discharge the clients home

when transferring a client from the emergency department to the acute care unit